Health inspection·February 28, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 2 of 6 residents (Resident #1 and Resident #2) reviewed for baseline care plans. The facility failed to ensure Resident #1 and Resident #2 had baseline care plans completed within 48 hours of admission. This failure could place newly admitted residents at risk of receiving inadequate care and services. Findings included: 1. Record review of the face sheet dated 2/28/24 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including anxiety, diabetes, hypotension (decreased blood pressure, chronic kidney disease, lack of coordination, shortness of breath. Record review of the MDS dated [DATE] indicated Resident #1 admitted to the facility on [DATE]. The MDS indicated Resident #1 was sometimes understood by others and sometimes understood others. The MDS indicated Resident #1 had a BIMS of 10 and was moderately cognitively impaired. The MDS indicated Resident #1 was dependent with toileting, lower body dressing, and putting on and taking off footwear, required maximum assistance with bathing, and moderate assistance with upper body dressing. Record review of the baseline care plan signed 2/13/24 indicated Resident #1 admitted to the facility on [DATE]. The baseline care plan indicated Resident #1 was vision and hearing impaired. The baseline care plan indicated Resident #1 was allergic to Lisinopril (medication to treat elevated blood pressure), Januvia (medication to treat diabetes), and Zosyn (an antibiotic). The baseline care plan indicated Resident #1 was a diabetic. The baseline care plan indicated Resident #1 was receiving IV medication. 2. Record review of the face sheet dated 2/28/24 indicated Resident #2 was a [AGE] year-old female initially admitted to the facility on [DATE] and then re-admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder, COPD, osteoporosis (a condition in which bones become weak and brittle), and [NAME]-[NAME] syndrome (a rare, serious disorder of the skin and mucus membranes). (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676335 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676335 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broadmoor Medical Lodge 5242 Medical Drive Rockwall, TX 75032 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)